Within REACH February_March 2020

Volume 11│Issue 1│February 2020 Carilion Medical Center, 1906 Bel leview Ave, Roanoke, VA 24014 https://www.insidecarilion.org/hub/nursing -research-evidence-based-practice nursingresearch@carilionclinic.org (540)266 -6216

Time to Celebrate!

Kim Carter, PhD, RN, NEA-BC - Senior Director, Nursing Research, EBP & Excellence Nurses “devote their lives to caring for mothers and children, giving lifesaving immunizations and health advice, looking after older people and generally meeting everyday essential health needs. They are often the first and only point of care in their communities.”1 To recognize this extraordinary work, the World Health Organization has partnered with the International Confederation of Midwives, International Council of Nurses (ICN), Nursing Now, and the United Nations Populations Fund to establish 2020 as the Year of the Nurse and the Midwife.1 To achieve a goal of universal health coverage in the next decade, 9 million more nurses and midwives are needed globally.1 Seizing this opportunity, the ICN and Nursing Now “are urging world leaders to make massive investments in nursing and midwifery to pave the way for a brighter future for health around the world”.2 Nursing Now Co-chair Lord Nigel Crisp adds, “The evidence is clear… investing in nursing and midwifery will make an enormous contribution to the rapid, cost-effective and high quality scaling up of universal health care.”3 The Year of the Nurse and Midwife offers nursing an opportunity to articulate “the amazing difference nurses can make…when they are properly supported and well educated,” states ICN CEO Howard Catton.2 ICN President Annette Kennedy urges nurses to share their stories about what it means to be a nurse, explaining that “increasing the public’s understanding of who nurses are, what they do, and the amazing contribution they make to the societies they live in, will help us to ensure that the legacy of 2020 will go on for years in the shape of more and better supported nurses providing essential care in the communities they serve.”2 How appropriate that the Year of the Nurse and the Midwife occurs in the same year as the 200th anniversary of Florence Nightingale’s birth (May 12, 1820 in Florence Italy).4 Nightingale transformed nursing through her tireless work and writings – she shared the stories of what it means to be a nurse. Two centuries later, it is up to us to fan the flame sparked by the Lady with the Lamp. It’s time to celebrate! This year, among many other activities, Carilion Nursing will celebrate nursing scholarship at the Art & Science of Nursing Showcase (May 11, 2020) among other Week of the Nurse activities throughout the system, and the Nursing Research Conference is being planned to celebrate Nursing’s rich traditions.

This edition of Within REACH highlights nursing scholarship, disseminates evidence and best practices, and celebrates the REACH and impact of Carilion nurses locally, nationally, and globally. Join us in this edition as we launch our own Year of the Nurse and Midwife Celebration!

~ Kim *References on page 4

Carilion Clinic Roanoke Campus

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ARTICLES/NOTIFICATIONS Time to Celebrate!

Kim Carter, PhD, RN, NEA-BC 3 Week of the Nurse Art & Science of Nursing Showcase Invitation 4 Cover article references. Celebrate our Nurses photos 6 A Systemic Review of the Impact of Essential Oil Aromatherapy on Nurse Work-Related Stress Taylor Brogan, BSN, RN, CCRN; Sandra Hubbard, BSN, RN; Kalyn O’Conner, BSN, RN 12 Pressure Ulcer Prevention: Using Preventive Dressings in the Operating Room Whitney Ashley, BSN, RN, CNOR 16 Strategies to Achieve Strong Response Rates to Surveys Kim Carter, PhD, RN, NEA-BC 1

RECOGNITION/EVENTS 18 Recognition 22 Conference Corner 24 Citations & Recognitions 26 See Where Our Nurses Have Travelled!

27 2020 Nursing Research Classes - Information 28 Additional Nursing Research Class Information

Carilion Nursing Research Editorial Board: Kim Carter, PhD, RN, NEA-BC - Editor-in-Chief Michele Kosinski, DNP, MBA, RN - Co-Editor Deirdre Rea, DNP, RN-BC, PMH-CNS - Co-Editor Reviewers Nancy Altice, DNP, RN, CCNS, ACNS-BC Desiree Beasley, MSN, RN, CCRN, CCNS Ann Beheler, ADN, RN Sarah Browning, DNP, RN-BC Molly Clemons, RN, ONC Monica Coles, DNP, RN-BC, ACNS -BC Sarah Dooley, MPH, BSN, RN Christine Fish-Huson, MSN, RN Shanna Flowers, MA Donna Goyer, BSN, RN, CPAN, CAPA

Cindy W. Hodges, BSHS, RNC, FCN James Ingrassia, MSN, RN Pam Lindsey, MSN, RN Margaret Perry, MSN, RN-BC Diana Talmadge, RN Cindy Ward, DNP, RN-BC, CMSRN, ACNS-BC Vivian Wilson, BSN, RN, CCRP Britmarie Witkowski, MPH

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GET READY TO CELEBRATE OUR WEEK OF THE NURSE EVENT!

Questions? Contact: Lisa Girani, BSN, RN - Co-Chair Week of the Nurse NRC Subcommittee, lagirani@carilionclinic.org Beth Assenat, BS - Administrative Coordinator, elassenat@carilionclinic.org

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References (from page 1) 1. World Health Organization. 2020. Year of the Nurse and the Midwife 2020. Accessed online on 2/26/20 at: https://www.who.int/news-room/campaigns/year-of-the-nurse-and-the-midwife-2020 2. International Council of Nurses. 2020. 2020 International Year of the Nurse and the Midwife. Accessed online on 2/26/20 at: https://www.icn.ch/news/2020-international-year-nurse-and-midwife-catalyst-brighterfuture-health-around-globe 3. International Council of Nurses and Nursing Now. 2019, December 30. Press Release from Geneva, Switzerland. Accessed online on 2/26/20 at: https://www.icn.ch/sites/default/files/inline-files/PR_59_% 202020%20International%20Year%20of%20the%20Nurse%20and%20Midwife.pdf 4. Selanders, L. 2020. Florence Nightingale: British Nurse, Statistician and Social Reformer. Encyclopaedia Britannica. Accessed online on 2/26/20 at: https://www.britannica.com/biography/Florence-Nightingale/ Homecoming-and-legacy

CELEBRATE OUR NURSES!

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A Systemic Review of the Impact of Essential Oil Aromatherapy on Nurse Work-Related Stress Taylor Brogan, BSN, RN, CCRN; Sandra Hubbard, BSN, RN; Kalyn O’Conner, BSN, RN - 9M NTICU *Editors note: This EBP Analysis was completed through an EBP Concentration with the Office of Nursing EBP & Research. Mentor - Kim Carter, PhD, RN, NEA-BC Stress occurs when the physical and psychological borders of an organism are threatened 1.

Intermittent stress poses little threat to the body; however, when stress is experienced for long periods of time with moderate to severe intensity, anxiety can follow. Nurses who experience high levels of stress for long periods of time are at increased risk of psychological issues such as depression and low self-esteem, as well as physical symptoms such as increased blood pressure and cardiovascular disease2. They are also more likely to leave their current position or leave the nursing profession all together2. Nurses report that factors that increase job-related stress are moral distress, increased workloads, increasingly higher patient acuity, physician communication struggles, and poor leadership3. The result of this cumulative stress can be increased job dissatisfaction, symptoms of moral burnout, and high turnover rates4.

Research indicates that nurses who have higher resilience and a larger arsenal of coping mechanisms are better able to cope with work-related stress and are less likely to experience symptoms of moral distress and burnout. One alternative coping mechanism that may be helpful is aromatherapy. Aromatherapy is defined as the "safe and professional use of essential oils, which are extracted and processed from a plant's bark, flower, root, peel or leaf" 5, p. 95. In addition, clinical aromatherapy is the practice of using essential oils for specific quantifiable effects on the human mind, body and spirit. Holistic approaches to managing stress in the healthcare setting, such as the use of aromatherapy, are supported by the American Holistic Nurses Association 6 because of the impact on positive health behaviors, resilience, and improved nurse-patient communication, care and satisfaction5.

The purpose of this work was to identify current knowledge related to the use of aromatherapy to decrease stress for nurses. The Neuro-Trauma Intensive Care Unit (NTICU) experienced a 26% staff turnover percentage in the 2018 fiscal year. The unit based shared governance initiative for 2019 focused on improving staff wellbeing by identifying and reducing the symptoms and causes of stress and burnout. The emphasis on wellness practices to promote resilience and coping led to the development of this study.

PICOT question: In ICU nurses, what is the effect of essential oil aromatherapy with peppermint, lavender, lemon and bergamot on work-related stress?

Search Strategy and Screening Summary The study focused on four commonly used essential oils: peppermint, lavender, lemon and bergamot. CINAHL, HERO and TRIP were searched to find peer reviewed, evidence-based articles written in English using the terms, “nurs*, essential oil, peppermint, lavender, lemon, bergamot.” Clinically based, nursing specific studies were chosen for review. Organizational websites such as the American Association of Critical Care Nurses (AACN) and the American Holistic Nurses Association (AHNA) were also consulted. In addition, current Carilion policies were reviewed. The findings were analyzed using a matrix.

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Summary of the literature The literature was separated into general aromatherapy, peppermint, lavender, lemon, and bergamot (Table 1).

General Aromatherapy Li and colleagues (2019) conducted a systematic review which analyzed ten articles, and six were relevant to the review criteria7. Four of the articles within Li, et al.’s review demonstrated a beneficial effect on nurse stress. Of the two studies of aromatherapy massage, one showed aromatherapy massage has statistically significant positive effects on stress level reduction in nurses. The other study showed no difference in stress levels of nurses; however, anxiety was reduced. Li, et al. concluded that there is not enough evidence related to the use of aromatherapy, massage, or aromatherapy massage to reduce nursing stress.They recommend more high-quality studies to understand the effects of aromatherapy on nursing stress.

Peppermint Four articles related to peppermint were identified. These studies included 3 randomized controlled trials and 1 non-randomized controlled trial.

Toda8 found salivary cortisol levels, a marker of stress, showed a statistically significant decrease after inhaling peppermint. The participants also had a decrease in subjective perception of stress following peppermint inhalation. Varney 9 demonstrated decreased feelings of burnout among the participants.

Seo10 used a powered sample and found that aromatherapy mouthwash significantly lowered perceived stress and Xerostomia, and although not statistically significant, objective halitosis was reduced. Lee11 demonstrated that perceived stress and depression were significantly lower, but there was no difference in symptoms of physiological stress (stress index, ANS activation, or glycated hemoglobin). This study also showed significantly longer sleep and improved sleep quality, but no significant difference in immunity11.

The findings related to peppermint consistently support peppermint’s potential effect on subjective perception of stress reduction.

Lavender

Four articles related to lavender were identified. These studies included three quasi-experimental designs and one non-randomized controlled trial.

Eren12 performed a quasi-experimental study with a powered sample and found there was no difference between the control and experimental groups regarding reduced stress and anxiety.

Chen13 used a non-randomized, controlled study and demonstrated a decrease in stress; however, that decrease was not noted until two days after therapy began. Johnson 4 and Pemberton14 also conducted quasi-experimental studies that both demonstrated a decrease in stress as a result of aromatherapy. Eren12 noted that in addition to the aromatherapy, the time away from patient care to conduct the study, may also have contributed to the reduced stress.

Johnson4 noted that staff preferred peppermint and lavender over other oils.

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Lemon Two articles related to lemon were identified. These studies included one single blinded randomized controlled trial and one quantitative randomized controlled trial.

Glaser15 examined the effects of lavender and lemon essential oils through a single blinded randomized controlled trial15. The participants in this study were not nurses but college students visiting hospital units who were asked to inhale these oils during their visit. While there were no significant results for lavender, there was clear and consistent evidence that lemon oil inhalation enhances positive mood and boosts norepinephrine release. One limitation of the study was a complex set of outcomes and designs. More study is needed with simpler design and outcomes.

Johnson5 examined the effects of lemon essential oil aromatherapy on test anxiety in nursing students. This quantitative randomized controlled trial concluded that due to a small sample size that led to no statistically significant data, more studies are warranted. One thing to gain from this study, however, is the recommendation that the practice is safe, and there were no adverse effects reported. The safety of aromatherapy is supported by the American Holistic Nurses Association as mentioned in this article.

More study is needed to understand the safety and potential effect of lemon on enhancing mood.

Bergamot One article was found evaluating the use of bergamot 16. This quantitative quasi experimental pilot study set out to determine if there was a link between bergamot essential oil aromatherapy and well-being in a clinical waiting room. The experimental group reported higher scores of feeling proud and "active," but also an increase of feeling nervous. The nervousness could potentially be due to the situation of awaiting an appointment. The results showed no adverse effects which may support the safety of aromatherapy in a clinical setting.

More study is needed to understand the safety and potential effect of bergamot on enhancing mood.

Implications for practice and policy Carilion policies related to essential oil diffusers are ambiguous and open to interpretation.

The decoration policy indicates that all products must be flame retardant and have appropriate documentation from the original packaging. Any cool-mist diffusers used would need to meet this standard. The decoration policy also states: "Plug in air fresheners, heated wax air fresheners and other heat producing devices used to produce aromas are not permitted." The cool mist diffuser is not considered an air fresher nor a heated source; therefore, clarification on this policy may be necessary moving forward.

The Carilion Professional Appearance Policy states that, "Colognes, perfumes, scented lotions, body sprays and after shave lotion should not be used because many patients and staff have sensitivities, allergies or respiratory conditions that may be compromised by scents." Based on the current Carilion policy, personal aromatherapy, such as that found in studies where participants attached cotton balls to their clothing, would not be appropriate. This policy does not address the diffusion of oils.

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A cool-mist diffuser is not on the list of contraindicated devices in the personal electrical appliance policy; however, the list states it is not all inclusive. This policy also states that appliances should be battery powered only and should not be used if it is disturbing to other persons in the area.

Considering this, a battery powered diffuser may be an appropriate option. Clarification would be needed on whether a diffuser would be classified as a personal electrical appliance if used at the nurses’ station or other area.

Carilion New River Valley Medical Center (CNRV) has an aromatherapy policy for the use of essential oil aromatherapy for patients. Key points in this policy include: • • • •

Administration is overseen by a certified aromatherapist, Only therapeutic grade essential oils are used, Both topical and aerosol diffusion is used, Therapy is provided after being ordered or approved by the physician.

Conclusions This EBP analysis identified evidence to support a positive correlation between peppermint, lemon, and lavender aromatherapy and stress reduction. There was limited evidence for bergamot use. While some essential oils can have side effects, the oils in this study were considered safe to use by diffusion. The quality of the evidence was AACN level B and C. This evidence analysis had some limitations. There is a lack of strong literature regarding aromatherapy practices with nurses, and some studies did not have powered sample sizes. In addition, perceived stress was not consistently measured across studies. The studies evaluated had limited control. For example, study participants may have engaged in other stress relief practices outside of the study that were not controlled for in the study design. Another example of limited control is that the condition of the participant’s patients may have changed during a given shift impacting the nurse’s perceived stress at a given time but was not evaluated as an extraneous variable. Bias in the literature favoring aromatherapy practices and personally using essential oils may exist. More work is needed to evaluate and clarify Carilion policies for relevance to diffused aromatherapy.

Based on this EBP review, we recommend that the Nursing Practice Council review Carilion Clinic policy to address essential oil use in the clinical setting. The current evidence is limited, and further research is needed to determine the relationship between essential oil use and a reduction in work related stress in the clinical setting.

References 1.

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Eren, N., Oztune, G., (2017). The effects of aromatherapy on the stress and anxiety levels of nurses working in Intensive Care Units. International Journal of Caring Sciences, 10(3), 1615-1623.

Roberts, R. & Grubb, P. (2013). The consequences of nursing stress and need for integrated solutions. Rehabilitation Nurse, 39(2), 62-69. doi: 10.1002/mj.97 Rushton, C., Batcheller, J., Schroeder, K., & Donohue, P. (2015). Burnout and resilience among nurses practicing in highintensity settings. American Journal of Critical Care, 24(5), 412-420. doi: 10.4037/ajcc2015291 Johnson, K., West, T., Diana, S., Todd, J., Haynes, B., Bernhardt, J., & Johnson, R. (2017). Use of aromatherapy to promote a therapeutic nurse environment. Intensive & Critical Care Nursing, 40(1), 18-25. doi: 10.1016/j.iccn.2017.01.006 Johnson, C. (2019). Effect of inhaled lemon essential oil on cognitive test anxiety among nursing students. Holistic Nursing Practice, 33(2), 95-100. doi: 10.1097/hnp.0000000000000315 American Holistic Nurses Association. www.ahna.org. (2019). Accessed 2019.

Li, H., Zhao, M., Shi, Y., Xing, Z., Li, Y., Wang, S., Ying, J. … Sun, J. (2019). The effectiveness of aromatherapy and massage on stress management in nurses: A systematic review. Journal of Clinical Nursing, 28(3/4), 372-385. doi: 10.111/jocn.14596

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Toda, M. & Morimoto, K. (2011). Evaluation of effects of lavender and peppermint aromatherapy using sensitive salivary endocrinological stress markers. Journal of the International Society for the Investigation of Stress, 27(1), 430-435.

Varney, E., Buckle, J., (2013). Effect of inhaled essential oils on mental exhaustion and moderate burnout: a small pilot study.

Journal of Alternative and Complimentary Medicine, 19(1), 69-71. doi: 10.1089/acm.2012.0089 Seo, E., Song, J., Hur, M., Lee, M., Lee, M. (2017). Effects of aroma mouthwash on stress level, xerostomia, and halitosis in healthy nurses: A non-randomized controlled clinical trial. European Journal of Integrative Medicine, 10(1), 82-89. doi: 10.1016/j.eujim.2017.03.001 Lee, M., Lim, S., Song, J., Kim, M., & Hur, M. (2017). The effects of aromatherapy essential oil inhalation on stress, sleep quality, and immunity in healthy adults: Randomized controlled trial. European Journal of Integrative Medicine, 12(1), 79-86. doi: 10.1016/j.eujim.2017.04.009 Eren, Nadiye Baris; Oztunc, Gursel. (2017). The Effects of Aromatherapyon the Stress and Anxiety Levels of Nurses Working in Intensive Care Units. International Journal of Caring Sciences, 10(3), 1615-1623.

Chen, M., Fang, S., Fang, L., (2015). The effects of aromatherapy in relieving symptoms related to job stress among nurses.

International Journal of Nursing Practice, 21(1), 87-93. doi:10.1111/ijn.12229 Pemberton, E. & Turpin P. (2008). The effect of essential oils on work-related stress in intensive care unit nurses. Holistic Nursing Practice, 22(2), 97-102.

Glaser, K., Graham, J., Malarkey, J., Porter, W., Lemeshow, K., & Glaser, S. (2008). Citrus limonum (lemon), not lavandula angustifolia (lavender), refreshes the senses? Retrieved from Wiley Online Library.

Han, X., Gibson, J., Eggett, D., & Parker, T. (2017). Bergamot (citrus bergamia) essential oil inhalation improves positive feelings in the waiting room of a mental health treatment center: A pilot study. Phytotherapy Research, 31(1), 812-816. doi: 10.1002/ptr.5806

Figure 1.

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Table 1. Evidence related to select aromatherapies and stress, anxiety, burnout, mood, and sleep

Key: AACN Levels of Evidence, Armola R., Bourgault A., Halm M, et al. 2009. Crtical Care Nurse, 29(4), 70-73 Level A-Meta-analysis of multiple controlled studies or meta-synthesis of qualitative studies with results that consistently support a specific action, intervention or treatment.

Level B - Well-designed controlled studies, both randomized and nonrandomized, with results that consistently support a specific action, intervention, or treatment.

Level C - Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results.

Level D - Peer-reviewed professional organizational standards, with clinical studies to support recommendations.

Level E - Theory-based evidence from expert opinion or multple case reports.

Level M - Manufacturers’ recommendations only.

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Pressure Ulcer Prevention: Using Preventive Dressings in the Operating Room Whitney Ashley, BSN, RN, CNOR - Operating Room Patients are sicker and require more advanced health care and longer admissions which places them at risk for decubitus from decreased mobility. The operating room is one of the many places in a hospital where patients are in the same position for a long period of time, putting them at risk for skin and tissue damage. Surgeries are more complex and require longer time spent in the surgical suite. There are many interventions for positioning of patients during surgeries, such as preventive dressings for pressure points when lying supine or laterally.

This evidenced-based literature review explores the efficacy of silicone dressings to prevent the development of pressure ulcers during surgery. The use of these dressings could reduce the risk of compromised skin integrity that could lead to infection, increased length of stay or readmission, and risk for multiple surgical debridements.

Review of Literature Standard Practice Pressure ulcer prevention is a Joint Commission National Patient Safety Goal1. Most hospitals have a standard pressure ulcer prevention protocol, or policy, in place. Within the literature, the phrase “SKIN Bundle� is used in combination with preventive dressings. This phrase refers to surface, keep moving, incontinence, and nutrition2. Current pressure ulcer prevention measures include frequent turning or repositioning, managing moisture and incontinence, selection of an appropriate mattress, managing a proper nutritious diet, reducing friction or shear injuries, and providing education on prevention3. Even with these standards, pressure ulcers still develop in all areas of the hospital.

Perioperative nurses should always perform a thorough skin assessment. Intraoperatively, the focus is on positioning prior to the upcoming surgery. The nurse should always have appropriate support surfaces available to help with pressure redistribution. The intraoperative nurse should be aware of how long the surgery will be, and that a pressure ulcer could develop from extended surgical time up to 72 hours after surgery4. Other risk factors that should be known are the type of surgery, anticipated blood loss, chance of hypothermia, and types of anesthetic agents used during the surgery5.

Standard operating room tables come with a tempur-pedic type mattress, and there are also pillows made of the same material that can be used to pad the knees and legs during prone positions. Other interventions include the use of approved headrest devices made of foam, gel pads, and the Pink PadÂŽ positioning system that is made of a material to contour to the patient and help prevent slipping when placed in steep Trendelenburg positions which could cause shear and friction injuries6.

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Silicone Border Dressings Several studies examined use of silicone border dressings to prevent pressure ulcers, in combination with standard pressure ulcer measures. In one trial, the silicone dressing was used in conjunction with either off-loading the heels or not of the subject. There was a significant difference (p=0.001) in pressure ulcer development due to elevation of the subjects’ heels; while the dressing itself did not reduce the incidence of pressure injuries, it did reduce the risk of injuries by reducing shearing forces5. Santamaria, et al. examined the use of a five-layer foam dressing on ED and ICU patients7. These patients were all placed on a low air loss mattress and given routine pressure ulcer prevention. The results showed a 10 percent lower occurrence rate for the intervention group who wore the silicone dressing7. Park suggest that the five-layer silicone dressing may prevent formation of stage one ulcers8.

Cost savings for hospitals and patients with the 5-layer silicone dressing have been demonstrated.

Padula suggested that given the estimated cost it takes to care for someone who already has a stage three or four ulcer, using the dressing could save $200,000 to $600,000 per year 3. Kalowes conducted a randomized trial of 366 patients with both groups receiving the standard SKIN bundle, but the intervention group added the 5-layer silicone dressing2. The effectiveness of the dressing resulted in significant cost savings.

In the operating room, a silicone preventive dressing is recommended in combination with approved positioning surfaces and devices already in use to help protect the skin from breakdown and decrease friction or shear injuries when moving the patient. The dressing may also improve the microclimate of the skin5. Common areas to apply the dressings for a patient in the supine position for a surgery lasting more than three hours are the sacrum and heels4.

Other Preventative Dressings and Measures Hydrocellular foam dressings, hydrocolloid dressings that contain a ceramide-2, fatty acids oil, and polyurethane film dressings were studied. In a three-group trial, Aloweni et al. administered the standard of care to each group, which consisted of repositioning of patients every three hours, use of positioning devices, the use of an alternating air mattress, use of slide sheets, frequent elimination rounds, and standard skin care which involves application of a barrier cream 9. The other two intervention groups added a fatty acid oil spray and a foam silicone dressing to the standard of care protocol. Aloweni et al. demonstrated that the foam dressing outperformed (p=0.04) the oil spray, and the standard of care group9. Another trial examined a Smith & Nephew hydrocellular dressing for patients who were in surgery for more than four hours, experienced cardiac arrest, experienced shock or sepsis, or were on vasopressors for more than 48 hours.

Pressure ulcers for the three study units ranged from 6.98 to 13.00 per 1000 patient days pre-intervention and decreased to 3.4 to 7.6 per 1,000 days with the hydrocellular dressing 1.

Another trial compared 64 subjects receiving polyurethane film (control) to 66 subjects receiving a ceramide-2 containing hydrocolloid dressing (intervention). Five subjects in the intervention group developed pressure injuries (7.6 %) compared to 13 subjects in the control group (20.3%) 10. Two out of these three trials were conducted outside of the United States, and these dressings may not be approved for use in the United States of America.

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Conclusion and Recommendations for Practice Most trials in the literature review used traditional pressure ulcer prevention measures or a SKIN Bundle as a control. For the operating room, traditional measures include mattresses that are designed for pressure redistribution, foam paddings, gel pads, and pillows4. Perioperative nurses should be mindful of length of surgery, friction and shearing when moving patients, proper use of positioning devices, types of anesthetics used, type of surgery, patient body temperature, and vasopressors4.

The ten articles included in this review demonstrated a need for more studies involving the use of preventive dressings. The most commonly used dressing in the United States is a soft silicone border dressing for the sacrum and the heels. The reviewed studies showed decreased ulcers in high-risk patients and decreased ulcer formation when used over bony prominences with surgical patients. These studies supported the use of dressings in conjunction with other standard of care pressure ulcer prevention strategies. Hydrocellular dressings are promising alternatives to a polyurethane film or fatty acid oil spray.

Based on this review, research at Carilion is warranted to trial preventive dressings in the operating room to reduce pressure ulcers in high risk patients, with specific focus on silicone border dressing in conjunction with traditional pressure ulcer prevention standards. An important component of this work will be the evaluation of financial impact to the organization and to patients.

References 1. Byrne, J. (2016) Prophylactic Sacral Dressing For Pressure Ulcer Prevention In High-Risk Patients. American Journal of Critical Care, 25(3), 228-234. doi:10.4037/ajcc2016979 2. Kalowes, P. (2016). Five-Layered Soft Silicone Foam Dressing To Prevent Pressure Ulcers In the Intensive Care Unit. American Journal Of Critical Care, 25(6), E108-E119. doi:10.4037/ ajcc2016875 3. Padula, W.V. (2017). Effectiveness and Value of Prophylactic 5-Layer Foam Sacral Dressings to Prevent Hospital-Acquired Pressure Injuries in Acute Care Hospitals: An Observational Cohort Study. Journal of Wound, Ostomy & Continence Nursing, 44(5), 413-419. doi:10.1097/ WON.0000000000000358 4. Spruce, L. (2017). Back to Basics: Preventing Perioperative Pressure Injuries. AORN Journal,105(1), 92-99. doi:10.1016/j.aorn.2016.10.018 5. Al-Majid, S., Vuncanon, B., Carlson, N. and Rakovski, C. (2017), The Effect of Offloading Heels on Sacral Pressure. AORN Journal, 106, 194-200. doi:10.1016/j.aorn.2017.07.002 6. Steck-Bayat, K.P., Henderson, S., Aguirre, A.G. et al. Prospective randomized controlled trial comparing cephalad migration in robotic gynecologic surgery using egg-crate foam versus the Pink PadÂŽ. J Robotic Surg (2019). https://doi.org/10.1007/s11701-019-00990-10.1111/ iwj.121017 7. Santamaria, N., Gerdtz, M., Sage, S., McCann, J., Freeman, A., Vassiliou, T., De Vincentis, S., Ng, A. W., Manias, E., Liu, W. and Knott, J. (2015), A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. Int Wound J, 12, 302-308.

8. Park Hee, K. (2014) The Effect of a Silicone Border Foam Dressing for Prevention of Pressure Ulcers and Incontinence-Associated Dermatitis in Intensive Care Unit Patients. Journal of Wound, Ostomy & Continence Nursing, 41(5), 424-429. doi:10.1097/

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WON.0000000000000046 9. Aloweni F., Lim, M.L., Chua, T.L., Tan, S.B., Lian, S.B., & Ang, S.Y. (2017). A randomized controlled trial to evaluate the incremental effectiveness of a prophylactic dressing and fatty acids oil in the prevention of pressure injuries. Wound Practice & Research, 25(1), 24-34.

10. Kohta, M., Sakamoto, K., Kawachi, Y., & Oh-i, T. (2015). A single-center, prospective, randomized, open- label, clinical trial of ceramide 2-containing hydrocolloid dressings versus polyurethane film dressings for pressure ulcer prevention in high-risk surgical patients.

Chronic Wound Care Management and Research, 2015, (1), 171-179.

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Strategies to Achieve Strong Response Rates to Surveys Kim Carter, PhD, RN, NEA-BC, Senior Director, Nursing Research, EBP & Excellence Nurse researchers often use surveys as a cost-effective strategy to measure knowledge, attitudes, and perceptions about topics that affect nursing practice and patient care 1,2. Although survey findings inform health policy and care delivery, low response rates to surveys are a consistent challenge for survey researchers in healthcare2. Technological advances in business have introduced the opportunity for administration of surveys using computer and web-based strategies3. However, regardless of the methodology implemented to administer the survey, use of random sampling and strong response rates decreases nonresponse bias (the threat that those who do not response are different from those who do respond) and increases confidence in the results being a reflection of the population2-4. Nurses and other healthcare workers are bombarded with requests to complete surveys, so it is important to incorporate a solid plan for achieving a strong sample size into the study design to ensure that the study achieves meaningful and generalizable data.

In a meta-analysis of strategies to improve response rates by health care professionals, Cho and colleagues noted that monetary incentives improve participation 2. While a $1.00 incentive may be enough to encourage response, higher incentive amounts over $30.00 were needed to achieve a 60% response rate2. This cost must be factored into the overall cost of the study, and the amount will be considered by the IRB to ensure that coercion is not a threat and that potential risks of study participation are not overshadowed by the amount of the incentive 2. Other studies have similarly found that small monetary incentives improve nurse response rates, but nonmonetary tokens, like pencils and pens, are less effective for nurses and physicians 1.

Consideration of how the survey is delivered and follow-up strategies will also enhance survey response rates1,2. In a 2013 meta-analysis2, Cho noted that higher response rates were achieved with postal surveys. The literature incorporated into their review would now be over a decade old; therefore, it is possible that the preference for mailed paper surveys has changed. Cho suggests that a mixed approach using multiple survey completion alternatives (mailed and electronic) offers the most flexibility to allow completion at the respondent’s convenience 2. Hoddinott & Bass propose that the Dillman Total Design Survey Method is an effective approach to achieve strong survey response rates5. Bogue and Carter used a modified version of the Dillman approach for survey research (manuscript under development) at Carilion, achieving a strong sample size. The Dillman method consists of multiple steps in the survey methodology, including prenotification by a key organizational leader, specific instructions, a means for removal of identifiers and ensuring anonymity, how the questions are presented, color of ink/font, and a precise pattern for follow-up at one, three, and seven weeks5. Personalized prenotification and sponsorship is useful3, especially when surveys are sent through programs such as REDCap, to assure the participant that the survey email and link are legitimate.

Reminders and prompts are effective1. Very specific details should be thoughtfully attended to when planning survey studies. For example, VanGeest & Johnson’s systematic review of how to improve response rates illustrates the impact of type of mailing, noting that first class postage did not result in improved response rates, but certified mail yielded better response. Careful attention to the wording of the reminder is important, and the reminder is most effective if the survey tool or link is again included with the reminder, rather than expecting the recipient to track down the previous invitation and survey1.

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New and innovative approaches to conducting surveys are arising, such as using web-based bulletin boards and other forms of social media3. These approaches allow for more qualitative data collection and may reach groups that may not participate in typically designed survey studies. Survey fatigue is an ongoing challenge, which underscores the need to careful consideration that only well-designed and meaningful surveys, with the minimum number of items necessary, are administered.

Nurses as a group may be homogeneous (similar) because of their shared knowledge, education, and employment1. However, efforts to encourage strong response rates will improve the confidence in and usefulness of survey findings.

References 1. VanGeest, J. & Johnson, T. 2011. Surveying nurses: Identifying strategies to improve participation.

Evaluation and the Health Professions, 34(4), 487-511.

2. Cho, Y., Johnson, T., & VanGeest, J. 2013. Enhancing surveys of health care professionals: A meta-analysis of techniques to improve response. Evaluation and the Health Professions, 36(3), 382-407.

3. Cope, D. 2014. Using electronic surveys in nursing research. Oncology Nursing Forum, 41(6), 681-682.

4. Taherdoost, H. 2017. Determining sample size; How to calculate survey sample size. International Journal of Economics and Management Systems, 2.

5. Hoddinott, S. & Bass, M. 1986. The Dillman Total Design Survey Method: A sure-fire way to get high survey return rates. Canadian Family Physician, 32, 2366-2368.

Gotta complete that survey!

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Courage!

Sara Wohlford, MPH, RN Carilion Clinic Emergency Department American Journal of Nursing (AJN) Mentored Writing Award Sara was selected as the winner in the 2019 Nurse Faculty Scholars Mentored Writing Award Program for her article, “Increased nursing engagement improves sustainability outcomes for healthcare”. This is an annual program to promote mentorship and develop scholarly writing skills among nurses. It was conceived by the 2012-2015 cohort of The Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholars Program to continue the legacy of mentorship and to support scholarship development for all nurses, and AJN is continuing this program as part of their mission to support excellence in nursing publishing. Kim Carter was Sara’s mentor for this submission and Nathalia Esteves-Fuentes was a co-author of this paper scheduled to be published in 2020.

Commitment!

Cathy Jennings, DNP, RN, ACNS-BC CRMH Cardiac Surgery Distinguished Fellow of the National Academies of Practice in Nursing (NAP) A Distinguished Pracitioner, Scholar or Policy Fellow within NAP is a very high honor that acknowledges outstanding achievements in the Field of Nursing. Cathy will be inducted during a black tie Gala at the 2020 Annual Meeting and Forum in San Diego, CA where she will be awarded the distinctive NAP medallion.

Cathy has tirelessly served the cardiac surgery program at Carilion Clinic for 37 years. Cathy lends her expert research skills and mentoring capabilities throughout the Carilion system. *Update - Due to the COVID-19 restrictions in place the gala has been cancelled with no estimated date of rescheduling.

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Commitment!

Phyllis Whitehead, PhD, APRN, ACHPN, RN-BC Distinguished Fellow of the National Academies of Practice in Nursing (NAP) A Distinguished Pracitioner, Scholar or Policy Fellow within NAP is a very high honor that acknowledges outstanding achievements in the Field of Nursing. Phyllis will be inducted during a black tie Gala at the 2020 Annual Meeting and Forum in San Diego, CA where she will be awarded the distinctive NAP medallion.

NAP members work collaboratively as an interprofessional community to influence and promote national health policy, legislation, quality healthcare, and research. Phyllis has committed herself to finding better ways to address moral distress and burnout in staff, as well as new opportunities in researching pain management in palliative care.

Update - Due to the COVID-19 restrictions in place the gala has been cancelled with no estimated date of rescheduling.

Collaboration! .Charles Bullins, II, DNP, RN Cardiac Surgery Acute Care Nurse Pracitioner Team Appointed as New Chair of Adult-Gerontology Acute Care Nurse Practitioner Content Expert Panel The American Nurses Credentialing Center (ANCC) has appointed Charles as the new Chair of Adult - Gerontology Acute Care Nurse Practitioner Content Expert Panel. The appointment will be from October 1, 2019 to December 31, 2021.

Charles is committed to the process of bringing gold standard cardiac care resuscitation practices to the bedside of CRMH patients, through the implementation of Cardiac Surgery Advanced Life Support practices. Charles was also recently elected Vice President of the Virginia Nurses Association - Chapter 2 Roanoke Valley. *Update - Due to the COVID-10 restrictions in place the induction scheduled for March 2020 has been postponed

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Compassion!

Lia Boggs, BSN, RN, CPN Carilion Clinic Department of Pediatrics March of Dimes 2019 Virginia Nurse of the Year Award Pediatric Award Recipient The March of Dimes Nurse of the Year award honors extraordinary nurses in our area who go above and beyond to deliver compassionate care. There were 120 nurses nominated from across the state of Virginia, 8 of those nurses were from Carilion. The remarkable efforts of these individuals often go unsung and through the March of Dimes Nurse of the Year Award, they are able to honor those who make a difference in the lives of so many.

Compassion!

Lisa Dishner, MSN, MHA, RN-BC, NEA-BC, PRS Carilion Rehab - Child & Adolescent Health March of Dimes 2019 Virginia Nurse of the Year Award Behavioral Health Award Recipient The March of Dimes Nurse of the Year award honors extraordinary nurses in our area who go above and beyond to deliver compassionate care.

There were 120 nurses nominated from across the state of Virginia, 8 of those nurses were from Carilion. The remarkable efforts of these individuals often go unsung and through the March of Dimes Nurse of the Year Award, they are able to honor those who make a difference in the lives of so many.

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Compassion!

Garrett Lawhorn, BSN, RNC-OB, C-EFM Carilion OBGYN Maternal Fetal Health March of Dimes 2019 Virginia Nurse of the Year Award Women’s Health Award Recipient The March of Dimes Nurse of the Year award honors extraordinary nurses in our area who go above and beyond to deliver compassionate care. There were 120 nurses nominated from across the state of Virginia, 8 of those nurses were from Carilion. The remarkable efforts of these individuals often go unsung and through the March of Dimes Nurse of the Year Award, they are able to honor those who make a difference in the lives of so many.

Collaboration! .Brandon Jones, MSN, RN, CEN, NEA-BC Carilion Administration - Patient Experience Secretary of the Commonwealth Board Appointments: Board of Nursing Govenor Ralph Northam appointed Brandon to the Virginia Board of Nursing. His first term will be through June 2021

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Association of Rehabilitation Nurses REACH Conference, Columbus, OH Allison Parkhurst, BSN, RN and Kara Gibson, RN presented their Nursing Staff Satisfaction on Quality of Care Using a FIM-Based Acuity Tool at the November 2019 ARN conference. The poster focused on the increased acuity challenges on acute in-patient rehabilitation units. They studied the use of an evidence based acuity tool to ensure optimal patient staffing to help enhance nursing staff satisfaction.

(l-r: Allison Parkhurst, Kara Gibson)

American Medical Rehabilitation Providers Association (AMRPA) 2019 Fall Educational Conference & Expo, San Diego, CA Allison Parkhurst, BSN, RN also shared her study Nursing Staff Satisfaction on Quality of Care Using a FIM-Based Acuity Tool at the AMRPA fall conference in San Diego, CA. The conference focuses on the latest and most innovative strategies to keep rehabilitation professionals ahead of the curve, provide the highest quality of care, and share advocacy efforts.

American Association of Neuroscience Nurses (AANN) International Neurosciences Nurses Research (INNR) Symposium, Austin, TX Radford University Carilion assistant professor and Carilion Clinic Research Associate, Chris Huson, PhD, RN presented her study, “Perceived stress, cortisol, and depression in adults diagnosed with postconcussion syndrome at a conference that included nurse researchers from diverse disciplines.

The INNR addresses international neuroscience nursing research across the continuum of scientific inquiry: bench/basic research/translational research; and planned, ongoing and completed clinical trials.

Attendees heard from more than 30 world leaders in neuroscience nursing research.

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American Heart Association Scientific Sessions, Philadelphia, PA Samantha Hall, DNP, FNP-BC, CCRN traveled to Philadelphia to present her study Predictors of 30-Day Readmissions After Cardiac Surgery. She noted it was the largest conference she has attended in her nursing career.

The majority of her time was spent in the State of the Art Cardiovascular Care sessions. These sessions covered new guideline updates, advances in cardiovascular care including genetics and technology advances. One of the lectures was about the Apple Heart Study (conducted at Stanford). It focused on how Apple watches are being used to monitor patients irregular heart rhythms, including AFib. Samantha learned that the results of this trial will lay the foundation for further utilization of smart watches and devices to help identify and/or monitor our patients with previously unknown/ undiagnosed AF. She noted this may be potentially valuable in the post-cardiac surgery patients where AF is not an uncommon occurrence.

EBP Immersion - OnSite Workshops, Ohio State University Helen Fuld Health Trust National Institute for EBP in Nursing, Columbus, OH Kim Carter, PhD, RN, NEA-BC, Desiree Beasley, MSN, RN, CCRN, CCNS, Chris Monk, MSN, RN, NEA-BC, Laura Reiter, MSN, RN, CCRN, CNRN participated in the Ohio State University Helene Fuld Health Trust National Institute for Evidence-Based Practice in Nursing and Healthcare from March 2-6, 2020.

This workshop provides a “deep dive” immersion into evidence-based practice (EBP), which is a “problemsolving approach that integrates the conscientious use of best evidence, clinician expertise and patient preferences to make decisions”. Participants learn the step-by-step EBP process as well as effective strategies for implementing EBP in clinical or academic organization of any size or level of complexity.

Working with internationally renowned EBP experts and mentors, our team worked in small groups, receiving individualized attention to successfully identify practice challenges and PICO(T) questions, apply literature search and analysis techniques, and develop an action plan for implementing and sustaining EBP changes.

Watch future editions of Within REACH for their reflections of the experience and summary of the work that they did while there.

(l-r: Kim Carter, Desiree Beasley, Chris Monk, Laura Reiter)

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October 2019 - March 2020 Carter, K., Bogue, D. October, 11, 2019. Burnout, exhaustion, and communication: Nursing living the balance. ANCC MagnetÂŽ Conference, Atlanta, GA Whitehead, P. October 22, 2019. CNS impact on research, evidence based practice, performance improvement/quality improvement. NACNS Webinar. https://nacns.org/professional-resources/ education/archived-webinars/

Bond, D. March 10-13, 2020. Respiratory compromise -The CNS’s voice at the table.

NACNS Annual Conference, Indianapolis, IN Ward, C. March 10-13, 2020. Nursing burnout with substance using inpatients: A new hope. NACNS Annual Conference, Indianapolis, IN Whitehead, P. March 10-13, 2020. CNS impact on research, evidence based practice, performance improvement/quality improvement. NACNS Annual Conference, Indianapolis, IN Whitehead, P. March 10-13, 2020. The impact of moral injury/moral distress upon your clinical nurse specialist practice. NACNS Annual Conference, Indianapolis, IN

Parkhurst, A., Gibson, K. November 6-9, 2019.

Nursing staff satisfaction on quality of care using a FIM-based acuity tool. Reach 2019: Association of Rehabilitation Nurses (ARN), Columbus, OH. Bond, D., Robinson, D. March 5, 2020. Accuracy of counted respiratory rate, opioid administration, and impact on early warning systems. Carilion Quality Conference, Roanoke, VA. Bailey, B., Hudson, J., Carter, K. March 5, 2020.

The use of an early warning system to improve patient outcomes. Carilion Quality Conference, Roanoke, VA

Jennings, C., Andrews, S., Armbrister, D., Blaukovitch, S., Bolling, K., Bullins, C., Cardenas, A., Fisher, C., Holman, S., Huddleston, D., Joseph, M., Massey, K., Motley, J., Shelton, L., Sink, D. March 5, 2020. Timely ventilator weaning and extubation after cardiac surgery. Carilion Quality Conference, Roanoke, VA Bishop, S., Klawonn, N., Saville, L. March 12-14, 2020. Development of a consult service within a large hospital system. Perioperative Medicine Summit 2020, Society for Perioperative Assessment and Quality Improvement (SPAQI), Orlando, FL.

Wiseman, S., Harvey, E., Bower, K.L. December 2019. Direct peritoneal resuscitation: A novel adjunct to damage control laparotomy. Critical Care Nurse, 39(1), 37-46.

Clark, R., Jennings, C., Carter, K. January 2020.

Being a research mentor: A qualitative study.

Journal of Nursing Administration, 50(1),16-21.

Ward, C. January-February 2020. EditorialReflections on caring for an aging parent. MedSurg Nursing, 29(1), 7 & 55.

Bath, J. October 2019. Accepted by the American Nurses Credentialing Center (ANCC) to participate as an Item Writer, who will contribute questions that appear on ANCC certification exams and continuously participate in ANCC test development for a full 36 months.

Bullins, C. November 2019. Appointed by the American Nurse Credentialing Center (ANCC) as New Chair of Adult-Gerontology Acute Care Nurse Practitioner Content Expert Panel.

Wohlford, S. 2019. Awarded the American Journal of Nursing Mentored Writing Award. Mentor - Kim Carter. Co-Author - Nathalia Esteves-Furentes.

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Boggs, L., November 2019. Awarded 2019 March of Dimes Virginia Nurse of the Year - Pediatric Award Recipient - Winner Dishner, L. November 2019. Awarded 2019 March of Dimes Virginia Nurse of the Year - Behavioral Health Award Recipient - Winner Lawhorn, G. November 2019. Awarded 2019 March of Dimes Virginia Nurse of the Year - Woman’s Health Award Recipient - Winner Sawyer, A. November 2019. Awarded 2019 March of Dimes Virginia Nurse of the Year - Pediatric Award Recipient - Runner-up.

Jones, B. October 2019. Appointed by Govenor Ralph Northam as his Administration Appointment for the Board of Nursing.

Jennings, C. March 2020. Elected as a Dinstinguished Fellow of the National Academies of Practice (NAP) in Nursing.

Whitehead, P. March 2020. Elected as a Dinstinguished Fellow of the National Academies of Practice (NAP) in Nursing Carilion nurses nominated for the 2019 March of Dimes Virginia Nurse of the Year award included: A. Henry - NICU C. Tueller - Peds, Postal Ave. C. Ratliff - Infusion Center J. Redden - OR Services

Practical Applications of Nursing Inquiry

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Within REACH

“The World is a book, and those who do not travel read only a page.” – Saint Augustine United Kingdom

Nottingham

Natl. Harbor, MD Williamsburg

Palm

Anaheim

Greenville

Lake Buena Vista

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REGISTER IN CORNERSTONE to experience more of OUR RESEARCH CLASSES! *********** Time to Write: Open Mentored Writing Labs NR-CE037L April 28, 2020 - 2-4pm June 23, 2020 - 8-10am August 18, 2020 - 2-4pm October 20, 2020 - 2-4pm December 15, 2020 - 2-4pm ************* Practical Healthcare Applications NR-CE377L September 17, 2020 - 1-4pm ************* Pre-Nursing Fellowship Brainstorm Brief NR-CE354L September 22, 2020 - 4-5pm ************* Leadership Tips & Tools for Coaching Staff to Design Studies NR-CE165L September 24, 2020 - 2-4pm ************* Developing a Competitive Abstract for the Next Magnet Conference & Similar Events NR-CE335L October 6, 2020 - 12:15-2:15pm ************* From Clinical Question to Project Proposal NR-CE328L November 3, 2020 - 1-4pm

Need editorial or financial support to present your work at a national nursing conference?

Contact Nursing Research & EBP for: • Assistance with writing your abstract • Poster development • Financial support through Nightingale grants. nursingresearch@carilionclinic.org

Carilion Clinic Roanoke Campus